Knee replacement patients benefit when physician anesthesiologists quarterback care

Researchers at Kaiser Permanente, the country's largest health care maintenance organization (HMO), collected outcomes data after implementation of a perioperative surgical home (PSH) -- a patient-centered, physician-led system of team-based care that guides the patient through the entire surgical experience. The PSH was implemented at a large hospital that serves a diverse population of 300,000 patients.

"The patient rather than the surgery becomes the center, and the physician anesthesiologist proactively manages all aspects of care, before, during and after the surgery," says Chunyuan Qiu, M.D., lead author and physician anesthesiologist, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, Calif. "Before the PSH was implemented, there was no quarterback overseeing the entire process, leading to fragmented, disjointed care that caused delays."

The study included 546 patients who had knee replacement surgery within one year prior to the implementation of the PSH and 518 who had the procedure within one year after the PSH was in place. The national average for length of stay after knee replacement is 4 days and 40 percent of patients spend time at a skilled nursing facility after leaving the hospital. In the study, the average length of stay for the PSH group was 1.9 days, versus 3.2 days before the PSH was instituted. In the PSH group, 94 percent of patients went home after being released from the hospital, and 6 percent went to a skilled nursing facility. In the pre-PSH group, 80 percent of patients went home after being released from the hospital, and 20 percent went to a skilled nursing facility.

The 30-day readmission rate was low in both groups: 1.2 percent in the pre-PSH group and .9 percent in the PSH group. It was estimated that the cumulative reduced length of stay in the hospital and skilled nursing facility for all patients saved $1.4 million.

Researchers surveyed 130 patients in the PSH group: 71 percent rated their experience as excellent and 25 percent said it was satisfactory.

In the PSH, the physician anesthesiologist-led team performs a variety of tasks before, during and after the surgery. For example, prior to surgery, the anesthesia team meets with the patient to ensure appropriateness for surgery. The anesthesia team assesses social support and home safety issues, encourages smoking cessation, weight loss and exercise, and adjusts medications. Physical therapy is key to a good recovery. Therefore, the PSH includes preferences for pain control that will help patients begin physical therapy sooner. Under the PSH process, more than 70 percent of patients began physical therapy the day after surgery, versus none in pre-PSH group.

"The implementation of the PSH has been very beneficial, but we cannot pinpoint a single element that is responsible for its success," said Dr. Qiu. "It's an entirely new practice model that demonstrates the value of having physician anesthesiologists direct care of knee replacement patients. We believe the PSH model would benefit patients having other types of surgery as well."